NCG200543_DOSA Form_20240206

ROY COOPER
Governors
ELIZABETH S.BISER
Secretor)
DOUGLAS R.ANSEL NORTH CAROLINA
Interim Director Environmental Quality
Stormwater Delegation of Signature Authority Form (DOSA)
This form shall be used to delegate signature authority from the permit Owner(Permittee) to
another party. Only the Responsible Official defined below may submit permit applications and
reports required by the permit(such as Data Monitoring Reports and Annual Reports) until this
form is completed and submitted to the DE'MLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility and compliance for
emit compliance.
Permit Owner:The legal entity to which/whom a permit has been issued and may be an individual
or an organization such as a company or government agency. Every Owner is required to have a
Responsible Official who meets the legal signature authority requirements in 40 CFR 122.22,
summarized below:
• Fora corporation,the Responsible Official shall be a president,secretary,treasurer,or vice president
in charge of a principal business function,or another individual who performs similar functions for
the corporation,or the manager of one or more manufacturing,production,or operating facilities
who is authorized to make management decisions about the facility operation.
• For a partnership or sole proprietorship,the Responsible Official shall be a general partner or the
proprietor,respectively;or
• Fora municipality,State,Federal,or other public agency,the Responsible Official shall be either a
principal executive officer[City/County Manager]or ranking elected official[Mayor].
Please mail the DOSA Form with original wet signatures to: NCDEMLR Stormwater
Program, 1612 MSC,Raleigh, NC 2 7699-1612
Name of Organizational Entity
Wall Recycling,LLC
Responsible Official Name
Dustin Hill
Responsible Official Title: Chief Operations Officer
Email Address: [e-mail] Phone [phone]
MailingAddress 2310 Garner Rd
City Raleigh State NC Zip code 27610-4612
D_E Q�� North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
512 North Salisbury Street Ibl2 Mall service center Raleigh.North Carolina 27b99-lbl2
a+•�d__--� � 919.707.9200

A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Attach additional pages if you need more space.
Delegated Party Name Dan arboe
Delegated Party Title Area President of Landfill and Environmental Compliance
Permit Numbers) NCG130099,-120118,-130100,-130098,-200528,-130109,-130110
Email Address: [e-mail] I Phone [phone]
MailingAddress 2310 Garner Rd
City Raleigh State NC Zip code 27610-4612
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
G
Delegated Party Name Belinda Jarboe
Delegated Party Title Environmental Technician I
Permit Number(s) NCG130099,-120118,-130100,-130098,-200528,-130309,-130110
Email Address: [e-mail] Phone [phone]
MailingAddress 2310 Garner Rd
City Raleigh State I NC Zip code 27610-4612
Signature of Delegated Party
indicating acceptance of �i
Signatory Authority: o
Date
Delegated Party Name Zachary Garlick
Delegated Party Title Project Engineer
Permit Number(s) NCG130099,-120118,-130100,-130098,-200528,-130109,-130110
Email Address: [e-mail] Phone [phone]
MailingAddress 221 Harvester Dr
City Holly Springs State NC Zip code 127540
Signature of Delegated Party
indicating acceptance of
Signatory Authority: ,W &/
Date IOW3
Stormwater Permit Delegation of Signatory Authority Form
Page 2

A. Persons to Receive Signature Authority
The signatures of the persons listed below indicates their acceptance of signatory authority.
Attach additional pages if you need more space.
Delegated Party Name Rusty Norris
Delegated Party Title Senior Engineer
Permit Numbers) NCG130099,-120118,-130100,-130098,-200528,-130109,-130110
Email Address: [e-mail] Phone [phone]
MailingAddress 7033 Moresham Way
city Wake Forest State NE I Zip code 27587
Signature of Delegated Party
indicating acceptance of
Signatory Authority: I
Date O 2
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address: Phone
MailingAddress
City State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Delegated Party Name
Delegated Party Title
Permit Number(s)
Email Address: Phone
MailingAddress
city State Zip code
Signature of Delegated Party
indicating acceptance of
Signatory Authority:
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

B.Responsible Official Signature
The Responsible Official,as identified in accordance with 40 CFR 122,22,is the appropriate
individual with the authorityto sign and submit reports for the organization.
As the Responsible Official,1, Dustin Hill (printed name),
have the authorityto enter into thisAgreement for
Wall Recycling,LLC (Owner/Organization Name).
I request that the DEMLR Stormwater Program include the persons listed in Part A of this
form signatory authority for the above-named permit.
I acknowledge that I,and the persons listed in Part A of this form work at/for my
organization and have authorityto act as a signatory far purposes of the NCDEgs
electronic document systems.
By submittingthis application,1, Dustin Hill (printed name),have read,
understand,and accept the terms and conditions of the stormwater permit(s)for which I
am the Responsible Official.
esponsible Official Signature
Chief Operations Officer l 41 24 2 3
Title Date
Stormwater Permit Delegation of Signatory Authority Form
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